Case report

Open Access

Complications of spilled gallstones following laparoscopiccholecystectomy: a case report and literature overviewSophie Helme1*, Tushar Samdani2 and Prakash Sinha2

Addresses: 1Imperial College London, 10th Floor, QEQM Wing, St Mary’s Campus, 20 South Wharf Road, London, W2 1PD, UK2Princess Royal University Hospital, Farnborough, Kent, UK

Email: SH* - sophiehelme@hotmail.com; TS - drsam771@rediffmail.com; PS - prakash.sinha@bromleyhospitals.nhs.uk

*Corresponding author

Received: 8 October 2008 Accepted: 6 March 2009 Published: 24 July 2009

Journal of Medical Case Reports 2009, 3:8626 doi: 10.4076/1752-1947-3-8626

This article is available from: http://jmedicalcasereports.com/jmedicalcasereports/article/view/8626

© 2009 Helme et al; licensee Cases Network Ltd.This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0),which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Introduction: Gallbladder perforation is common and occurs in 6 to 40% of laparoscopiccholecystectomy procedures. In up to a third of these cases, stones are not retrieved andcomplications can arise many years post-operatively. Diagnosis can be difficult and patients maypresent to many specialties within medicine and surgery. We seek to present our case and review theliterature on prevention and management of “lost” stones.

Case presentation: Our patient is a 77-year-old woman who presented to the urology clinic with aloin abscess that developed five years after laparoscopic cholecystectomy. Radiological studiesshowed retained abdominal gallstones and an associated abscess formation. These were drainedunder ultrasound guidance on several occasions and the patient now suffers from chronic sinusitis.Due to her age and comorbidities, she has declined definitive surgical intervention to remove thestones.

Conclusion: Gallbladder perforation during laparoscopic cholecystectomy is a reasonably commonproblem and may result in spilled and lost gallstones. Though uncommon, these stones may lead toearly or late complications, which can be a diagnostic challenge and cause significant morbidity to thepatient. Clear documentation and patient awareness of lost gallstones is of utmost importance, as thismay enable prompt recognition and treatment of any complications.

IntroductionIn the current era of minimally invasive surgery, laparo-scopic cholecystectomy has become the gold standard forthe surgical treatment of symptomatic gallstones. How-ever, with the increase in the number of laparoscopicoperations performed, there has also been a noticeableincrease in the number of complications specific to these

procedures. Gallstones can be spilled during an opencholecystectomy, but these stones are eliminated usuallythrough direct removal, copious irrigation and moppingwith laparotomy sponges. In laparoscopic procedures,these techniques are more difficult or unavailable and sostones can disappear from view and can become “lost”.Studies show that the incidence of spilled gallstones

Page 1 of 4(page number not for citation purposes)

during laparoscopic cholecystectomy accounts for 6 to40% of procedures performed, while 13 to 32% of suchoperations result in lost stones [1,2]. Complications fromstones that are left within the peritoneal cavity can causeunusual but significant morbidity.

Case presentationA 77-year-old woman presented to the urology clinicwith a two-week history of night sweats, right back painand loin swelling. Her medical history included alaparoscopic cholecystectomy for gallstones five yearsbefore presentation. Other than a similar pain noticedsix months previously, there had been no knowncomplications from the surgery. On examination thepatient had a tender, fluctuant swelling in the right lumbarregion with overlying skin erythema. Her blood testsshowed a neutrophilia of 7.7 ¥ 109/litre and C-reactiveprotein of 134 mg/litre. A computed tomography (CT)scan showed a complex subphrenic, subhepatic andsubcutaneous collection. The patient’s abscesses weredrained under ultrasound guidance and the drains left insitu. The pus grew Escherichia coli on culture. The patientwas then treated with antibiotics for ten days anddischarged home.

Three weeks later the patient reattended hospital withsimilar symptoms and ultrasound and CT scans showed aperihepatic and subcutaneous reaccumulation of fluid,with a 1cm gallstone adjacent to the right lobe of her liver(Figure 1). The abscesses were again drained. A barium

enema of the colon was arranged to exclude a neoplasticcause for the abscess, but the result simply showed mildsigmoid diverticular disease and no fistulous connection.In addition, a contrast study through the percutaneousdrain did not reveal any connection with intra-abdominalviscera. Therefore, the patient was diagnosed with intra-abdominal sepsis secondary to retained gallstones at thetime of her laparoscopic cholecystectomy.

Subsequently, the patient was treated as an out-patient,but her ultrasound scans (USS) continued to showcollection of pus, which had to be drained three moretimes. The patient also developed chronic sinus discharge,and still went to the out-patient clinic 18 months after herinitial presentation. A sinogram showed her sinus con-necting with the right paracolic gutter and extendingupwards and posteriorly (Figure 2). After identification ofthe offending gallstone on a second CT scan, the patientwas offered surgery to remove the offending gallstones butdeclined this mode of treatment. At the time of writing shewished to continue with conservative management unlessfurther problems arise.

DiscussionWe reviewed the published literature on spilled stonesafter laparoscopic cholecystectomy to discuss the risks,complications and management of patients who sufferfrom these lost stones.

Figure 1. CT demonstrating perihepatic gallstone.Figure 2. Sinogram showing contrast running up the rightparacolic gutter.

Page 2 of 4(page number not for citation purposes)

Journal of Medical Case Reports 2009, 3:8626 http://jmedicalcasereports.com/jmedicalcasereports/article/view/8626

Risk of perforation of the gallbladderCertain situations lead to higher risk of gallbladderperforation during laparoscopic cholecystectomy. Patientswith acutely inflamed gallbladders have friable tissuewhich is susceptible to tear. Dense adhesions around thegallbladder make dissection potentially more difficult, anda tense, distended gallbladder that has not been decom-pressed is at risk of perforation [1,3]. This usually occurswhen the gallbladder is manipulated by laparoscopicinstruments or when it is dissected from the liver bed.Spilled stones are also caused by the slipping of the cysticduct clip or the tearing of the gallbladder while it isretrieved from the port site [4]. There is also a wellrecognised learning curve for performing laparoscopiccholecystectomies, and the risk of perforation is high earlyin a surgeon’s laparoscopic career [1].

Risk of complications from lost stonesAlthough lost gallstones were initially considered innoc-uous, it is now recognised that they can be a small butsignificant source of postoperative morbidity (0.1 to 6%)[4]. The presentation of complications will vary frompatient to patient, and depend largely on the site and typeof complication suffered. Recognised symptoms includeabdominal pain, fever, abdominal masses, bowel obstruc-tion and the presence of a sinus infection or fistula [2,5]. Insome cases, the presenting mass has been diagnosed asmalignancy until further investigations have disprovedthis. In most instances, the diagnosis is made retro-spectively, or after visualisation of the stones on imagingand revisiting the patient’s surgical history.

Most complications occur within the first few months, butpresentations up to ten years after the procedure have alsobeen documented [6]. Zehetner et al. looked into alldocumented complications from lost gallstones and theseranged from the most common like intra-abdominal andsubcutaneous abscesses and fistulas, to the less common,such as liver abscess, staphylococcus bacteraemia, bronch-olithiasis and expectoration, empyema, granulomas,bowel obstruction and incarceration within a hernialsac [5].

Studies also show risk factors for complications afterspilled stones, such as the presence of infected bile,spillage of pigmented gallstones, multiple stones (>15),stone size (>1.5 cm) and old age [5].

Prevention and management of spilled stonesThe best way to avoid complications from lost gallstones isto have awareness of the situations where perforation islikely, perform precise dissection, meticulously handletissue and use devices such as endobags to retrievedissected gallbladders through the port sites. Perforationusually occurs when dissecting the gallbladder from the

hepatic fossa, and care taken at this stage of the operationcan save many minutes attempting to retrieve stones fromwithin the peritoneum [7].

Despite all precautionary measures, it is unavoidable thatgallbladder perforation and stone spillage still occur insome patients. In these cases, it is crucial to minimise thenumber of stones spilled, attempt to retrieve all straystones and to copiously irrigate the peritoneal cavity [4].This serves the purpose of diluting any infected bile andmay allow the stones to be washed up into the suctionsystem. Some surgeons advocate the use of clips or anendoloop to close the hole in the gallbladder, whileothers will introduce a retrieval bag and ‘park’ it on theliver to receive all spilled stones [7]. In some situations itmay be necessary to use an extra port adjusted to a 30- or45-degree scope or use a fan liver retractor to improvevisualisation [4].

Antibiotic prophylaxis is not routinely used by everyone,but its therapeutic use has been suggested for patients whoundergo laparoscopic cholecystectomy to treat acutecholecystitis, have visibly infected bile, or have a highprobability for lost stones. However, antibiotics shouldnot be administered until the bile and stones have beencollected for examination and culture, which would allowfor the antibiotic selection to be tailored to the patient’scondition [5].

Possibly the most important aspect in the management ofperforated gallbladders and potential stone spillage isdocumentation. As already mentioned, diagnosis ofcomplications related to lost stones is often done onlyafter the identification of gallstones on radiologicalimaging. If the documentation is clear and the patient isaware of the perforation, then clinicians may be alertedearly to the possibility of a stone complication in order toexpedite treatment.

Management of complicationsThe imaging method of choice is usually ultrasound, asstones are usually visualised well using this method.Visualisation, however, depends on the location of thelost stones. CT and magnetic resonance imaging (MRI)can also be used to obtain adjunct images depending onthe biochemical composition of the stone. Radio-opaquecalcified stones, such as pigmented stones, can be seenclearly on CT with unenhanced pictures. On MRI moststones are hypo-intense on T2-weighted images and iso-intense to hyperintense on T1-weighted images. These arebest seen without fat suppression as this allows for thecontrasting features of the stone to be seen against the fat[8]. Sometimes the radiological findings mimic unusualdiagnoses such as actinomycosis, hydatid disease or evenmalignancy, so diagnosis can be difficult [1]. Ultimately,

Page 3 of 4(page number not for citation purposes)

Journal of Medical Case Reports 2009, 3:8626 http://jmedicalcasereports.com/jmedicalcasereports/article/view/8626

abscesses should be drained, whether percutaneously orsurgically, and the stones should eventually be removed.Ideally this is done via minimally invasive techniques, butopen surgery is often required. However, in our case, thepatient was not keen on further invasive procedures and sofor her the sequelae of lost stones may continue for years.

ConclusionsGallbladder perforation during laparoscopic cholecystect-omy is a reasonably common problem and may result inspilled and lost gallstones. Though uncommon, thesestones may lead to early or late complications, which canbe a diagnostic challenge and cause significant morbidityto the patient. Proper care should be taken to avoid stonespillage. Should spillage occur, clear documentation and ahigh index of suspicion for complications should bemaintained for early recognition and treatment ofcomplications from this surgery.

AbbreviationsCT, computerised tomography; USS, ultrasound scan;MRI, magnetic resonance imaging.

Competing interestsThe authors declare that they have no competing interests.

ConsentWritten informed consent was obtained from the patientfor publication of this case report and any accompany-ing images. A copy of the written consent is available forreview by the Editor-in-Chief of this journal.

Authors’ contributionsSH wrote the bulk of the manuscript and researched theliterature. TS wrote some parts of the manuscript and alsoresearched the literature. PS edited the final version.

AcknowledgementsImperial College London has funded the publication ofthis article.

References1. Bhatti CS, Tamijmarane A, Bramhall SR: A tale of three spilled

gallstones: one liver mass and two abscesses. Dig Surg 2006,23:198-200.

2. Yadav RK, Yadav VS, Garg P et al: Gallstone expectorationfollowing laparoscopic cholecystectomy. Indian J Chest Dis AlliedSci 2002, 44:133-135.

3. Frola C, Cannici F, Cantoni S et al: Peritoneal abscess formationas a late complication of gallstones spilled during laparo-scopic cholecystectomy. Br J Radiol 1999, 72:201-203.

4. Hand AH, Self ML, Dunn E: Abdominal wall abscess formationtwo years after laparoscopic cholecystectomy. JSLS 2006,10:105-107.

5. Zehetner J, Shamiyeh A, Wayand W: Lost gallstones in laparo-scopic cholecystectomy: all possible complications. Am J Surg2007, 193:73-78.

6. Chowbey PK, Bagchi N, Sharma A et al: Abdominal Wall Sinus: Anunusual presentation of spilled gallstone. J Laparoendosc Adv SurgTech A 2006, 16:613-615.

7. Patterson EJ, Nagy AG: Don’t cry over spilled stones? Compli-cations of gallstones spilled during laparoscopic cholecys-tectomy: case report and literature review. Can J Surg 1997,40:300-304.

8. Karabulut N, Tavasli B, Kiroglu Y: Intra-abdominal spilledgallstones simulating peritoneal metastasis: CT and MRimaging features (2008: 1b). Eur Radiol 2008, 18:851-854.

Page 4 of 4(page number not for citation purposes)

Journal of Medical Case Reports 2009, 3:8626 http://jmedicalcasereports.com/jmedicalcasereports/article/view/8626

Do you have a case to share?

Submit your case report today• Rapid peer review• Fast publication• PubMed indexing• Inclusion in Cases Database

Any patient, any case, can teach ussomething

www.casesnetwork.com